Life-Threatening Allergic Reactions Rising in Children

Anaphylaxis is the scary end of allergy, the kind of reaction that can kill. It can happen almost immediately after the exposure — being stung by the bee, eating the peanut — and it can move fast. In anaphylaxis, your immune system turns against you with a vengeance, revs up and releases histamines and other chemicals that set off a range of dangerous physiological changes.

Your airways squeeze tighter, so it’s harder to breathe — especially dangerous in children, who start with smaller airways. Your lips and tongue and throat can swell. Your blood pressure can drop until you’re in shock. You can also get hives, you can develop nausea and vomiting, all possible clues to the advent of anaphylaxis.

A new report from Blue Cross Blue Shield looked at allergy diagnoses and at emergency room visits for anaphylaxis from 2010 to 2016 among their subscribers, who include 9.6 million children 18 and under all over the country. The report showed an increase in the incidence of children being diagnosed as “at risk” for anaphylaxis over the course of those seven years. And correspondingly, the rate of emergency room visits for anaphylaxis more than doubled, to 3.5 visits per 10,000 children in 2016 from 1.4 in 2010.

Of those emergency room visits, 47 percent were attributed to specific food allergies, largely peanuts and tree nuts and seeds. The other 53 percent were attributed either to unknown foods or “to other unspecified causes.” (Because the study was done by examining insurance claims, the information is conveyed by billing codes; some codes specify “anaphylactic reaction due to shellfish,” for example, but others just say, “anaphylactic shock, unspecified.”)

Dr. Trent Haywood, the chief medical officer of the Blue Cross Blue Shield Association, said that one reason for doing the study was “to make parents aware before the situation occurs.” Alerting parents seemed particularly crucial, he said, because of the recent controversy about the high cost of EpiPens, the epinephrine autoinjectors commonly prescribed for children at risk, so they have emergency treatment available at home and at school — and wherever they go.

Regardless of cost or controversy, “What we don’t want anyone to do is say, because the cost is going up, maybe be less vigilant,” Dr. Haywood said. “Because we’re seeing a doubling of the incidence, it’s even more important you’re vigilant on this particular issue.”

Guidelines for parents were published in March in JAMA. It’s possible that the increased incidence of emergency room visits may in part be good news; parents may be watching more closely, noting early signs of possible anaphylaxis, using their EpiPens (anyone who uses one needs to be seen immediately in an emergency room, in case the reaction recurs or continues).

“Severe reactions can happen at any time,” said Dr. Anna Volerman, an assistant professor of medicine and pediatrics at University of Chicago Medicine who was the lead author of an article summarizing current clinical guidelines for peanut allergy prevention, also published in JAMA in March. Because parents generally make changes in the home to keep the risky substances away from the child, “most allergic reactions that are severe happen outside of the household,” she said.

That means that parents have to make sure there is an awareness of the allergy — and of how to react — wherever the child spends time, from school to after school activities and sports. And it’s also important, she said, to make sure that the child has “a really strong understanding of the allergy, and feels comfortable speaking up and saying, ‘I’m allergic to X, is there any X in this food item.’”

“Other parents see this in terms of the things they can and can’t bring to school for their child or bring to a birthday party,” she said, but for parents who have a child with a food allergy, “it affects everything from food to child care.”

Children with allergies or asthma — problems which also represent revved-up immune systems — are at higher risk to have anaphylaxis, and a child who has had anaphylaxis in the past, even a comparatively mild bout, is at higher risk to have it again, and perhaps more severely.

“I do recommend an EpiPen for anybody who has a history of anaphylaxis or severe reaction or has a history of significant food allergy,” Dr. Volerman said. When she prescribes one, she goes over the potential signs and symptoms of an allergic reaction. “I talk about lip swelling, hives in combination with nausea or coughing, or throat discomfort, tongue swelling, throat tightening, trouble breathing, dizziness, lightheadedness.”

And it’s most important that it be with the child, and be used if necessary — or even if possibly necessary. She tells parents: “If you think about using an EpiPen, go ahead and use it if you notice any of these signs and symptoms.”

Many more children in the Blue Cross Blue Shield study had allergies of the type that do not cause anaphylaxis, with common diagnoses including allergic rhinitis and seasonal allergies, and also allergic dermatitis; 25 percent of the children up to the age of 2 had an allergy diagnosis, but the percentage dropped in older children.

And the suggested clinical guidelines on preventing peanut allergy, which is the leading cause of fatal anaphylaxis from a food allergy, now include introducing peanut-containing foods earlier than we used to give them; children with severe eczema or egg allergy need to be evaluated first for peanut allergy, and depending on the results, the doctor may recommend introducing peanut-containing foods at 4 to 6 months. (Of course, no babies or toddlers should ever get actual peanuts, which present a choking hazard.)

“For a long time we thought we should avoid foods,” Dr. Volerman said. “The guidelines now reflect that we should be exposing children to peanuts early. It could lower the chances of your child developing an allergy.”

But for children who do have allergies, parents and teachers — and the children themselves — need to be vigilant and quick to act when it comes to anaphylaxis; this is a diagnosis that is much better to overcall than undercall. And many of the children in the Blue Cross Blue Shield survey had not previously been given diagnoses of allergies, Dr. Haywood said. So anaphylaxis, a potentially life-threatening reaction that can be effectively treated if you treat it promptly, is also a diagnosis that everyone should be ready to recognize, history of allergy or not.